ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain After 2 hours of Independent: Goal met. After

related to nursing 2 hours of
“Nasakit unay ti chemical burn interventions, • Assess pain These data can be used nursing
tiyan ko, lalu nu of gastric the patient will characteristics to identify the extent of interventions,
kalkalpas ko mucosa verbalize relief (quality, severity, the pain as well as the patient
mangan.” from pain and location, onset, serve as a baseline verbalized relief
rate it as 2/10 duration, precipitating information. from pain and
Objective: from 7/10. and relieving factors). rated it as 2/10
• Restless from 7/10.
• Observe or monitor Some people deny the
• Pacing signs and symptoms
• Rigid experience of pain
associated with pain, when it is present.
abdomen such as BP, heart
• Self- Attention to associated
rate, temperature, signs may help the
focused color and moisture of
• Wrinkled nurse in evaluating
skin, restlessness, pain.
nose and ability to focus.
• Raised
upper lips • Assess for probable
• Rapid cause of pain.
breathing
• Rated pain Different etiological
as 7/10 in factors respond better
• Assess patient’s
a pain to different therapies.
knowledge of or
scale of 0- preference for the
10 array of pain-relief
strategies available. Some patients may be
unaware of the
effectiveness of
nonpharmacological
methods and may be

BAUTISTA, Jesther Rowen, SN IV

 willing to try them,
either with or instead
of traditional analgesic
medications. Often a
combination of
therapies (e.g., mild
• Assess patient’s analgesics with
willingness or ability distraction or heat)
to explore a range of may prove most
techniques aimed at effective.
controlling pain.

Some patients will feel

uncomfortable
exploring alternative
• Anticipate need for methods of pain relief.
pain relief. However, patients need
to be informed that
there are multiple ways
to manage pain.

• Respond immediately One can most

to complaint of pain. effectively deal with
pain by preventing it.
Early intervention may
decrease the total
amount of analgesic
required.

BAUTISTA, Jesther Rowen, SN IV

 In the midst of painful
experiences a patient’s
perception of time may
• Eliminate additional become distorted.
stressors or sources Prompt responses to
of discomfort complaints may result
whenever possible. in decreased anxiety in
the patient.
Demonstrated concern
for patient’s welfare
and comfort fosters the
development of a
• Encourage small, trusting relationship.
frequent meals

Patients may
• Identify and limit experience an
foods that cause exaggeration in pain or
discomfort such as a decreased ability to
spicy foods and tolerate painful stimuli
carbonated drinks. if environmental,
intrapersonal, or
• Encourage to assume intrapsychic factors are
position of comfort. further stressing them.

Dependent: Small meals prevent

distention and gastrin
• Administer analgesic release.
for relief of pain (e.g.
morphine sulfate).

BAUTISTA, Jesther Rowen, SN IV

 Food has acid
• Administer antacids neutralizing effect and
(e.g. Magnesium dilutes gastric content.
Hydroxide Aluminum
Hydroxide)
Reduces abdominal
tension and promotes
Collaborative: sense of control.

• Provide and
implement prescribed
dietary modifications.
Relieves abdominal
pain by reducing the
peristaltic activity.

Helps relieve pain by

neutralizing stomach
acid and increasing
bicarbonate and mucus
secretion.

Patient may receive

nothing by mouth
initially. When oral
intake is allowed, food
choices will depend on

BAUTISTA, Jesther Rowen, SN IV

 the diagnosis.

BAUTISTA, Jesther Rowen, SN IV